Provider Demographics
NPI:1740372903
Name:WOUND TREATMENT MEDICAL ASSOCIATES OF THE SOUTH SHORE
Entity type:Organization
Organization Name:WOUND TREATMENT MEDICAL ASSOCIATES OF THE SOUTH SHORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDEWATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-256-6576
Mailing Address - Street 1:900 FRANKLIN AVENUE
Mailing Address - Street 2:WOUND TREATMENT MEDICAL ASSOCIATES OF THE SOUTH SHORE
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580
Mailing Address - Country:US
Mailing Address - Phone:516-256-6576
Mailing Address - Fax:516-256-6888
Practice Address - Street 1:900 FRANKLIN AVENUE
Practice Address - Street 2:WOUND TREATMENT MEDICAL ASSOCIATES OF THE SOUTH SHORE
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580
Practice Address - Country:US
Practice Address - Phone:516-256-6576
Practice Address - Fax:516-256-6888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY137566261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WNW241Medicare PIN